Call the midwife: Minnesota study finds that communication matters

Women who use midwives for prenatal care feel less rushed and more comfortable asking questions, according to a University of Minnesota study, which argues for greater use of midwives in low-risk pregnancies or reforms that give doctors more time to listen to patients.

Women were twice as likely to hold back questions when seeing doctors rather than midwives, according to the study released Tuesday.

"That's a lot of women who are not asking things that maybe they should be," said Katy Kozhimannil, the lead author, who is a U public health researcher and a practicing doula. Even granting that physicians can intimidate some patients, Kozhimannil said she found the results surprising.

And while nearly 54 percent of women felt their doctors used words they didn't understand, 40 percent of women using midwives felt the same way. The research was based on a survey of 2,400 women who gave birth at U.S. hospitals in 2011 and 2012.

Whether better communication produces better medical outcomes was not addressed by the study. There is ample research showing that physician experience produces better outcomes, so even crusty, reserved doctors could be perfectly good choices.

But Kozhimannil said there is also research showing the value of patient-centered care and documenting that patient engagement can produce better outcomes as well.

Simply answering questions thoroughly can also relax pregnant women, Kozhimannil added. "How labor progresses is a direct result of how stress hormones act in the body," she said.

"I really do get those 'door-handle' questions," Swigert said. "I go back in the room and sit down because those often are the most important questions for patients."

Midwives perform the majority of prenatal care in certain European countries, and are the default providers for low-risk pregnancies in the British health system. But they remain something of an outlier in U.S. medicine. In the U.S. survey, 8 percent of the patients chose midwives for prenatal care. The survey did not distinguish between licensed midwives and certified nurse midwives with advanced nursing degrees.

Kozhimannil's study found that many women who chose midwives in the U.S. group did so because they were referred or assigned to them. Health insurance coverage was paramount in their choice as well. This suggests an opportunity for insurers or family practice doctors to refer patients to nurse midwives, Kozhimannil said, who tend to cost less but perform equally well in managing low-risk pregnancies.

Medical schools have already been responding to the communication issue by increasing training on listening to patients, Swigert said, and clinics have developed alternatives such as group prenatal care appointments to help patients ask questions and hear others' questions.

" 'Can I color my hair?' 'What are safe foods to eat?' " Swigert said are the sorts of questions that can pop up. "It's interesting because one of our patients might ask a question that another hadn't thought of."

Those relationships are especially important in the case of pregnancies that turn out more complicated than expected — when patients may need to transition from midwives to obstetricians, Swigert said.

"Midwives are only trained to handle low-risk deliveries. One important part of the communication between a midwife and a physician is to make sure the midwives are recognizing when they do need a physician."